Posterior only approaches versus anterior only approaches and combined posterior and anterior approaches for lumbar tuberculosis in adults: minimum 5-year follow-up

Abstract

Objective To compare the minimum 5-year follow-up outcomes of surgical management by posterior only, anterior only and combined posterior and anterior approaches for lumbar tuberculosis in adults, evaluate the mid-term follow-up results of the surgery for the treatment of lumbar tuberculosis and explore its advantages and indications. Methods From Jun 2004 to Jan 2010, 311 adult patients with lumbar tuberculosis were treated surgically. The clinical data of 137 cases that met the enrolled criteria and had integrity following-up data was analyzed retrospectively. It included the patients who had the surgical indication of the posterior only surgery but underwent the anterior only or the combined posterior and anterior approaches before 2008. There were 83 cases of male and 54 cases of female. The age ranged from 20 to 75 years, with a mean of 65.6 years. Among these patients, 63 cases were treated with single-stage posterior debridement, interbody fusion and instrumentation (the posterior group); 42 cases were treated with posterior instrumentation, and anterior debridement and bone graft in a single or two-stage procedures (the combined group) and 32 cases were treated with anterior debridement and strut grafting with instrumentation (the anterior group). Trauma index (the operation time, blood loss, the length of hospital stay, complications) ; imaging parameters (Segment kyphotic angle, corrective rate, loss angle, bone fusion time) and the quality-of-life indicators (Oswestry Disability Index、Frankle grade、visual analogue scale、Macnab score) were compared among three groups. Results The mean operation time, mean blood loss and the complications rate were (207.9 ± 30.9) min, (409.5 ± 107.9) ml and 12.95% in the posterior group; (270.7±32.0) min, (649.0±120.0) ml and 30.95% in the anterior group; (349.7±38.9) min, (840.0± 168.7) ml and 25% in the combined group. The operation time, blood loss and the complications rate of the posterior group were less than the anterior group and the combined group, and the difference was significant; The combined group consumed the longest operation time, associated with the most intraoperative blood loss, the highest complication rate and the longest hospital stay among the three groups, and the difference was significant. The correction rate of kyphosis achieved of the anterior group (52%± 5.45%) was significantly inferior to the posterior group (74%±5.04%) and the combined group (69%±7.95%), while the loss of correction in the anterior group (2.5°) was higher than both the posterior group (0.8°) and the combined group (1.1°), and the difference was significant. The average follow-up was (6.5±1.96) years (range, 5-11). The mean bone fusion time of the posterior group, the anterior group and the combined group were (6.0±1.5) months, (6.2±1.3) months and (6.5±1.6) months respectively, and there was no statistic difference. After the surgery, the quality of life was improved obviously in all patients. At the time of the latest follow-up, the improvement rate of the ODI,VAS and the excellent and good rate according to the Macnab score were 80.6%±2.1%, 81.7%±1.6% and 95.24% in the posterior group; 79.8%±1.5%, 79.7%±2.0% and 92.95% in the anterior group; 81.3%±1.1%, 79.9%±0.8% and 90.63% in the combined group. There was no significant difference among the groups in the improvement rates of the ODI, VAS, Frankel grade and the excellent and good rate of the Macnab score. Conclusion The Mid-term follow-up of the different surgical procedures for the treatment of the lumbar tuberculosis in adults were basically satisfactory. Compared with the traditional surgery, the posterior-only surgery is a safe, minimally invasive and effective method in the management of monosegment lumbar tuberculosis in adults. Key words: Lumbar vertebrae; Tuberculosis, spinal; Treatment outcome; Follow-up studies